Provider Demographics
NPI:1164401659
Name:TERRY, TED JAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:JAY
Last Name:TERRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2243
Mailing Address - Country:US
Mailing Address - Phone:541-267-6673
Mailing Address - Fax:
Practice Address - Street 1:470 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2243
Practice Address - Country:US
Practice Address - Phone:541-267-6673
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD42791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice